APMA News - July/August 2018 - APMA3

SUPPLEMENT TO APMA NEWS

YOUR APMA / PAGE 3

DOUBLE CHECK FOR ACCURACY
By Barbara Bellione, RN, CPHARM, ARM, director of Risk Management, PICA

One of the basic principles of medical record documentation is accuracy.
Inaccuracies, discrepancies, or inconsistences in the medical record can lead to
adverse events. They can also put the credibility of the entire record at jeopardy.
Consider the following actual case.

he patient was diagnosed by the
podiatrist with bursitis, hallux valgus,
and hammertoe deformities toes two
and four, left foot. After three months of
failed conservative treatment, the podiatrist
performed a Lapidus bunionectomy with a
harvested calcaneal donor bone graft, a left
second metatarsal dorsiflexion osteotomy,
and hammertoe corrections of the second
and fourth digits, left foot.
Immediately following surgery, the patient
awoke in extreme pain with muscle spasms
in her upper left thigh. The patient described
the pain as the worst pain she had ever
experienced and was hospitalized for pain
management. The patient subsequently
developed foot drop. She was evaluated by
a neurologist, who felt the patient developed
nerve damage as a result of the tourniquet
being inflated too long during the surgery
performed by the podiatrist.
The patient sued the podiatrist, alleging
failure to accurately document the length
of time the tourniquet was inflated during
surgery and negligently leaving the tourniquet inflated more than 90 minutes, causing
permanent injury and pain.
According to the operating room (OR)
record, the procedure start time was 14:41
and the end time was 17:32 (about two hours
and 50 minutes). The tourniquet inflation
time documented by the OR nurse on the
OR record was 12:41 with deflation time at
14:38 (one hour and 57 minutes). The OR

record then showed the tourniquet was again
inflated by the insured at 15:55 and deflated
at 15:26. Assuming the second documented
inflation and deflation times were mistakenly
reversed, the second tourniquet time was 29
minutes.
Due to the inaccuracies in the operative report, it is impossible to tell just when
the tourniquet was inflated and deflated.
The initial tourniquet time documented by
the OR nurse began two hours prior to the
surgery start time and ended three minutes

prior to the surgery start time. The nurse who
documented the tourniquet time admitted
in his deposition that the documented times
were incorrect and he did not know the correct times. If the assumption is made the
tourniquet was inflated at the beginning of
surgery and deflated at the end of surgery,
the total tourniquet time was two hours and
50 minutes. The podiatrist's operative report
was silent with regard to management of the
tourniquet.
The defense experts concurred that the
documentation in the medical record could
not be relied upon to prove appropriate use of
the thigh tourniquet. This case was resolved
prior to trial for a significant amount.
In this case, the OR nurse's documentation
was inaccurate. However, the podiatrist failed
to check the accuracy of the documented
tourniquet times and failed to accurately
document the tourniquet times in his operative report, negatively impacting the defense
of this case.
Review medical record documentation to
ensure entries made in the medical record
accurately reflect dates, times, the patient's
condition, your assessment, treatment provided, orders, patient instructions, etc. Accurate
records are not only vital for good patient
care, but they are also vital in the defense of
a malpractice claim should one arise.
For more information, contact PICA's Risk
Management department at 800-251-5727.

4.4375" x 3.375"

SpencoMedics

™

3-Pod™ GRF Technology
puts Spenco Medics™ Insoles
miles ahead of every other
professional preformed
orthotic device.
Ray Anthony,
FCPodS, DPodM, Podiatrist

http://www.spenco.com/medics

Table of Contents for the Digital Edition of APMA News - July/August 2018